Abdominal Wound Dehiscence

Presenter: T Mohammed Moderator: Dr H Pienaar

Introduction
Wound Dehiscence is the premature "bursting" open of a wound along surgical suture. It is a surgical complication that results from poor wound healing. Risk factors in general are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery. Sometimes a pink (serosanguinous) fluid may leak out.

Introduction
Abdominal wound dehiscence (burst abdomen, fascial dehiscence) is a severe postoperative complication, with mortality rates reported as high as 45%. The incidence as described in the literature ranges from 0.4% to 3.5%.

Introduction
Abdominal wound dehiscence can result in evisceration, requiring immediate treatment. Prolonged hospital stay, high incidence of incision hernia, and subsequent reoperations underline the severity of this complication.

Introduction
Despite advances in perioperative care and suture materials, incidence and mortality rates in regard to abdominal wound dehiscence have not significantly changed over the past decades. This may be attributable to increasing incidences of risk factors within patient populations outweighing the benefits of technical achievements.

Types of Wounds

Recent Literature
In this study by Van Ramshorst et al (World J of Surg 2010;34:20-27) the objective was to develop a risk model to recognize high risk patients and identify independent risk factors for abdominal wound dehiscence. The study was conducted at the department of surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Recent Literature
A total of 363 cases and 1,089 controls were analyzed. Major independent risk factors were: age, gender, chronic pulmonary disease, ascites, jaundice, anemia, emergency surgery, type of surgery, postoperative coughing, and wound infection.

Recent Literature
In the validation population, risk scores were significantly higher (P<0.001) for patients with abdominal wound dehiscence (n = 19) compared to those without (n = 677). Resulting scores ranged from 0 to 8.5, and the risk for abdominal wound dehiscence over this range increased exponentially from 0.02% to 70.1%.

Risk Formula
The validated risk model shows high predictive value for abdominal wound dehiscence and may help to identify patients at increased risk. The calculation of the probability of abdominal wound dehiscence for an individual surgical patient is performed in two steps.

Risk Formula
First, the total risk score is calculated by adding the weights of the various variables shown in Table 1. In the second step, the probability of developing abdominal wound dehiscence, P, is calculated according to the logistic formula: P= e/ (1+ex )x100%;where ex represents the exponential function and x represents -8.37 + (1.085 x calculated total risk score).

Risk Calculation
For example, the risk score for a 67-year-old man who undergoes an elective reconstruction of the abdominal aorta and is known to have a history of chronic pulmonary disease is 0.9 (score for age 60 69 years) + 0.7 (score for male gender) ? 1.3 (score for vascular surgery) + 0.7 (score for chronic pulmonary disease), for a total of 3.6. The probability, P, of this patients developing abdominal wound dehiscence is: e(-8.37+(1.085x3.6)) /1+e (-8.37+(1.085x3.6)) x100%= 1.1%

Risk Calculation
An emergency repair in a similar patient with a ruptured aneurysm and subsequent anemia results in a total score of 4.9 (i.e., subtotal of 3.6 points + 0.6 emergency + 0.7 anemia). Thus, the absolute risk rises to 4.5%.

Risk Score Intepretation

Risk factors
Patients who undergo emergency surgery are generally in worse condition and nutritional state, and the chance of contamination of the surgical field is higher than in elective surgery. Moreover, the performance of the surgeon might be affected at night, which could lead to suboptimal closure of the abdomen at the end of the operation.

Risk factors
Old age is another independent risk factor for abdominal wound dehiscence. Age has also been reported as a risk factor in other studies. The explanation for this might lie in deterioration of the tissue repair mechanism in the elderly. Especially during the first few days of the wound healing process, the immune system plays a key role.

Risk Factors
One of the interesting risk factors found in this Rotterdam study, is gender. In previous studies, males have been reported to have a higher risk of developing abdominal wound dehiscence. This was attributed to smoking as a possible confounder and its effect on tissue repair.

Risk Factors
Another explanation may be that men build up higher abdominal wall tension than females. An increase in intra-abdominal pressure results in higher strain on the wound edges, causing the sutures to cut through the muscles and fascia.

Risk Factors
In the Rotterdam study, wound infection proved to be the risk factor with the highest relative weight. Its importance has been confirmed by virtually every study on this topic. Continued presence of bacteria causes influx and activation of neutrophils and increases in levels of degradative matrix metalloproteinases (MMPs).

Risk Factors
In the absence of sufficient tissue inhibitors of MMPs, wound degradation will occur. The release of endotoxins by bacteria leads to the production of collagenase, which degrades collagen fibers. Infection thereby causes a prolongation of the inflammatory phase and negatively affects deposition of collagen and fibroblast activity.

Risk factors
In wounds of patients with abdominal wound dehiscence, it has been observed that degradation of collagen exceeds the synthesis of collagen, which adversely affects breaking strength. Adequate tissue breaking strength is necessary, however, to provide support for the sutures that hold the wound edges together.

Risk Factors
Low breaking strength can therefore amount to abdominal wound dehiscence, especially in the presence of increased intra-abdominal pressure and abnormal inflammatory response.

Risk factors
Primary repair can be difficult or impossible when tissue has low breaking strength, creating the need for the use of mesh or acceptance of the high risk of recurrent abdominal wound dehiscence.

Risk factors
Risk factors that did not have independent effects in the Rotterdam study included: 1.hypertension 2.uremia 3. corticosteroid use.

Risk Factors
The Rotterdam study found no significant effect on the occurrence of abdominal wound dehiscence for diabetes mellitus and previous laparotomy. Malignancy, sepsis, and postoperative vomiting have been identified as risk factors by several authors, but no significant effects were found in the present study.

Risk factors
This was surprising because it was suspected that the presence of scar tissue, microvascular changes due to hypertension and diabetes, poor tissue perfusion, and poor overall condition of the patient, associated with sepsis and malignancy, would be risk factors.

Risk factors
Jaundice, on the other hand, was found to be an independent risk factor. The conclusion of The Rotterdam study was that wound healing is affected in jaundiced patients due to the association with low hematocrit and albumin levels and malignancy (i.e., poor nutritional status) and not to raised bilirubin levels.

Risk Factors
Low protein and albumin levels and deficiencies of several vitamins and minerals such as vitamins A, B1, B2, B6, C and zinc, selenium and copper have been associated with poor wound repair.

Risk Factors
Anemia is a risk factor that is related to increased perioperative stress, blood transfusions, and decreased tissue oxygenation, all of which can affect the immune system and the wound healing process.

American Risk Model

A similar validation model of risk of dehiscence index was developed by an American group in Salt Lake City Utah in 2003 using data from the Veterans Affairs National Surgical Quality Improvement Program but lacks a formula for calculating the probability of developing dehiscence as in the Rotterdam Study.

American Risk Model

There are several limitations to this study. Because the veterans carry more comorbidities than the general population, our results may not be generalizable to the public at large.

Abdominal Wall Closure

For secure abdominal wall closures, the reduced tissue integrity along the border of the acute wound led to development of the concept of an optimal suture lengthto wound length (Suture Length-to-Wound Length) ratio for the primary closure of midline laparotomies .

Abdominal Wall Closure

Well-done, large, prospective studies with the best follow-up found that a SL-to-WL ratio of approximately 4:1 minimized the incidence of fascial dehiscence and incisional hernia formation; this is where the surgical training dictum of 1-cm bites followed by 1 cm of progress originated.

Conclusion
Important risk factors for abdominal wound dehiscence have been identified in the Rotterdam case-control study 2010 including: 1. age, 2. gender 3. chronic pulmonary disease, 4.ascites, jaundice, anemia, emergency surgery, type of surgery, coughing, and wound infection.

Conclusion
5.jaundice 6.anemia 7.emergency surgery 8.type of surgery 9.coughing 10.wound infection

Conclusion
A number of factors for abdominal wound dehiscence have been identified but the risk of developing abdominal wound dehiscence can be reduced by preventing pneumonia and wound infection, and by applying optimal surgical technique in every patient.

References
Abdominal wound dehiscence in adults. Van Ramshorst et al. World J of Surg 2010;34:2027. Prognostic models of wound dehiscence. Webster et al. J Surg Research 2003, 109: 130137. The biology of acute wound failure. Dubay et al. Surg Clin North Am 2003,83:464-481